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NONTRAUMATIC EMERGENCIES Flashcards

1
Q

Jason is 55 and diabetic. His foot has lost vascular blood supply to his toes and the tissue has died. What is this called?

A

Gangrene: tissue death d/t loss of blood supply

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2
Q

What are the three types of gangrene?

A
  • Dry: ischemia. extremities. dry, shrunk, black.
  • Wet: ischemia. Occurs in naturally moist areas (organs/mouth), lots of bacteria, fetid smell, sepsis.
  • Gas: C. perfringens, produce gas, spreads fast, emergency.
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3
Q

Martha presents to your clinic w/ a headache, fever and chills. The skin on her cheek is red, swollen, hardened and has an orange peel texture w/ sharp demarcation. What is this?

A

Erysipelas: Strep pyogenes infection of the upper dermis. TX w/ PCN

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4
Q

Murph is a 51 year old diabetic. He presents today with a hot, swollen lower left leg with redness and poorly demarcated borders. What is this?

A

Cellulitis. Staph/strep infection of lower dermis. TX w/ PCN

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5
Q

Jim and Betty come into your clinic again. Betty says that Jim has got a big zit on his back and she just can’t get it to drain. It’s red, tender and swollen. What is this?

A

Abscess. Staph in the dermal and deeper layers. Warm compress and I&D.

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6
Q

Ted is a burn patient that is following up with you. You saw hims 2 days ago and his lower arm had a large poorly demarcated area of redness and swelling that was shiny looking and extremely tender. He comes back today with a fever and the arm looks purple and gray with large bullae. He has lost sensation. The lesion appears to go down to the subQ and fascia. What do you suspect?

A

Necrotizing fasciitis

TX surgical debridement and ABX like Augmentin + Clinda

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7
Q

Mason is your 43 year old male patient who has had chronic gouty arthritis. After blood tests you decided he should be put on a xanthine oxidase inhibitor to lower his uric acid levels. You prescribe him allopurinol. You get a call from the ED the next morning and Mason was admitted to the burn unit for a diffuse mucocutaneous reaction causing detachment of the epidermis in his mouth and all over his body. What is this?

A

Stevens Johnson syndrome if 30% BSA
-usually drug reaction
Often allupurinol, Cox II and sulfa.
TX burn unit, supportive

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8
Q

Lina Wong is severely nearsighted woman who comes to the ED from a movie theater. She is complaining of nausea, HA, eye pain and vision loss associated with halos. What will her eye exam look like? How will this be treated?

A

Acute angle closure glaucoma

  • red eye, cloudiness, dilated and poorly reactive pupil
  • TX pressure lowering drops: pilocarpine. Systemic acetazolamide and surgery: peripheral iridotomy.
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9
Q

Sam is a 62 year old male with ASCVD, HTN and DM. He comes to the ED today complaining of painless monocular vision loss. On fundoscopy you see a lightening of the fundus, box carring of the arteries, and a cherry red spot on the macula. What is this?

A

Central retinal artery occlusion.

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10
Q

Tim is a 62 year old male with ASCVD, HTN and DM. He comes to the ED today complaining of painless monocular vision loss. On fundoscopy you see scattered and diffuse hemorrhage of retina w/ dilated and tortuous veins that could be described as “blood and thunder”. What is this?

A

Central retinal vein occlusion

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11
Q

Andy is a 12 year old who had a lacrimal gland infection a week ago. He comes in today and you notice proptosis, local redness and swelling to the periorbital region and he has pain with eye movement when you test EOMs. What is this?

A

Could be preseptal or orbital cellulitis. Need CT to distinguish.
If orbital = admit and give Vanc. + Ceftriaxone

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12
Q

Sean is a 60 year old nearsighted diabetic. He comes to the ED complaining of floaters, flashes and a curtain-like vision deficit. On fundoscopy you can only see part of the retina. What is this?

A

Retinal detachment. Often d/t posterior vitreous detachment.
Needs Opth. referral for photocoagulation, vitrectomy, cryo/pneumatic retinopexy, etc.

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13
Q

Lisa decides to skip taking her contacts out for a few days since it says on the contact box she can leave them in for a month. She wakes up this morning with eye pain, light sensitivity and feels like there is something in her eye that she can’t get out. What is this?

A

bacterial corneal ulcer secondary to bacterial keratitis.

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14
Q

You think your patient has bacterial keratitis. What can you do to diagnose this? Also, the patient wants some numbing medication for her eye. What should you prescribe?

A
  • DX: Stain exam shows white spot or opacity which suggests ulcer (surface breakdown/thinning/necrosis).
  • TX: referral to ophthalmologist same day! Ofloxacin/cipro/tobramycin eye drop ointment.
  • For pain give NSAID. No topical anesthetics as they delay healing.
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15
Q

Abdul comes in complaining of a red eye that is painful. He also says he can’t see well out of that eye. Eye exam shows a constricted pupil, leukocytes in the anterior chamber and perilimbal injection. What is this?

A

Uveitis

caused by infections, systemic inflammatory diseases, etc (herpes, syphillis, MS, CMV, IBD, Bechet’s. spondyloarthropathies, sarcoid)

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16
Q

Two days ago you saw a patient with a URI and an eye that had diffuse pink coloration, clear discharge and itching. You spent 15 minutes explaining that it was most likely viral and therefore you didn’t need to prescribe antibiotics and that the problem will resolve on its own. The patient is back complaining of continued symptoms, but now he feels like his vision is decreased and he feels like there is sand in his eye. You find multiple corneal infiltrates on eye stain exam….what could this be?

A

viral keratoconjunctivitis
often seen w/ adenovirus: URI and adenopathy.

Vision threatening, needs opth referal.

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17
Q

Ferris is your 47 year old male patient with rosacea. He comes to clinic c/o of swollen eyelid and discharge. What is this?

A

blepharitis
anterior= staph. and causes inflammation and seborrhea. Posterior=meibomian dysfunction, associated w/ rosacea and seborrheic dermatitis.

Warm compresses. Topical abx.

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18
Q

A diabetic patient comes in w/ painless monocular vision loss associated with a “shower” of floaters. You see fluid in the posterior chamber. What is this?

A

Likely a vitreous hemorrhage from retinopathy

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19
Q

Corbin has been stressed a lot lately. He just got sick, he’s working long shifts at work and has family to take care of. He wakes up this morning with severe eye pain and vision loss in his left eye. He has his preceptor do a fundoscopy at work and the preceptor sees papillitis. The preceptor also checks for pupil reactivity and notices that his direct response is sluggish compared to the indirect response (afferent pupilary defect). What do you suspect?

A

Optic neuritis

  • many causes: ischemia, infection, inflammatory, compression., common w/ MS..
  • Get MRI
  • TX w/ steroids
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20
Q

Robert is a 4 year old that’s been battling a chronic otitis media. You just notice that his left ear is poking out at and odd angle. He has tenderness, redness and swelling over the mastoid region. What do you suspect?

A

Mastoiditis

-Needs higher level of care. C&S, ABX, Drainage.

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21
Q

Cindy is your 3 year old with another bout of acute otitis media. On otoscopy you note that her TM in her right ear is blistering. What is this? What should you do?

A

Bullous myringitis

TX is same for AOM

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22
Q

What is the treatment protocol for acute otitis media in kiddos under 2 yoa? Over 2 yoa?

A

ABX if< 2 yoa.

If >2 yoa and F>102.2 and lasts >48hrs /bilat then abx, (amox) otherwise no abx.

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23
Q

It’s fall going into winter and you are getting a lot of kids between 6 and 36 months with fever, nasal congestion, hoarseness, stridor and a bark cough. You do a lateral neck x-ray. What do you find? What is this and its TX?

A

Croup: often parainfluenza
X-ray: steeple sign.
TX:Oral dex. for outpatient. O2, monitor, nebulized epi, dex. watch 3-4 hours.

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24
Q

A concerned mother brings her 5 year old, Tommy, into the ED for fever and sore throat. He is breathing fast and keeps his nose in a sniffing position to help with breathing. When you try to talk to him you notice his voice sounds like he has a hot potato in his mouth and that he’s drooling to keep from swallowing. You do an x-ray. What does it show? How will you treat this?

A

Epiglottis: lots of causes, think Hib if no vaccination

  • x-ray shows thumb-print sign.
  • Careful not to trigger further constriction of throat.
  • If epiglottis not enlarged then treat like croup. Don’t mess with airway unless ready to secure it. Give Ceftriaxone if enlarged.
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25
Q

Tom comes into the ED complaining of acute unilateral hearing loss. He asks you what some possible causes are and you respond……

A 
viral cochleitis (herpes), 
microvascular event, 
autoimmune (MS, Meniers), 
Acoustic neuroma, 
ototoxic drugs (aminoglycosides). 
TX: Steroid taper.
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26
Q

Ben comes into the ED complaining of vertigo. He asks you what some possible causes are and you respond……

A
  • disorders of vestibular system bppv, Meniere’s, labyrinthitis, vestibular neuronitis, herpes zoster, aminoglycoside, acoustic neuroma
  • disorder w/in CNS on brainstem (migraine, ischemia, MS)
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27
Q

Amy is a 74 year old that has a nose bleed. Where do 90% of nose bleeds originate?

A

90% ant. (keisselbach’s plexus: superior labial artery)

10% post (internal maxillary artery)

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28
Q

How will you treat a nose bleed?

A

TX lean fwd, manual pressure 15-20mn, topical oxymetazoline, silver nitrate. nasal tampons/balloons (esp for posterior).

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29
Q

Cindy comes to the ED complaining of fever, sore throat and dysphagia. On exam you notice drooling, hot potato voice and asymmetric oropharynx w/ displaced uvula. What are some infectious causes of this?

A

peritonsilar cellulitis or abscess: strep, mono

-CBC, Culture, rapid strep, monospot. US, CT. admit kids and give abx. PCN + Metro.

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30
Q

A 70 year old man comes in with a cough and pedal edema. CXR shows pleural effuson. What is on your differential?

A

CHF, Cirrhosis

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31
Q

A 44 year old COPD patient comes in with cough, pleuritic chest pain and fever. CXR shows pleural effusion. You decide to thoracentesis. What are the two types of fluid and what do they indicate?

A

transudate: chf, cirrhosis
exudate: pneumonia/infection, CA, PE

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32
Q

What sort of physical exam finding might there be with pleural effusion?

A

Asymmetric expansion.

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33
Q

What does a CXR look like w/ pleural effusion? How is it treated?

A

X-ray: blunted costophrenic angles, fluid layers on lat decubitus view.

Drain and treat cause

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34
Q

A COPD patient comes in w/ exacerbation of symptoms: increased dyspnea, cough, and sputum production. What is the most likely cause? How will you treat this?

A

Infection

O2 w/ neb of albuterol/tiatropium + systemic corticosteroid and Levofloxacin for infection.

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35
Q

What are some risk factors for pneumonia?

A

RF over 65, chronic disease, immune comp, recent ABX

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36
Q

What are typical bacteria associated with pneumonia? How do they often present?

A

SSHKN: Strep, Staph, H. Flu, Kleibsella, Neisseria

Pleuritic chest pain, productive cough, Fever, consolidation.

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37
Q

What are atypical bacteria associated with pneumonia? How do they often present?

A

MLCH: Mycoplasma, Legionella, Chlamydia

Low grade F, non productive cough, dyspnea, diffuse interstitial infiltrates. GI sx w/ legionella.

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38
Q

What percentage of CAP is caused by viruses?

A

approximately 50%

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39
Q

What are common viral etiologies of pneumonia? How do they often present?

A

: Adeno, Influenza, RSV

Fall/winter: non productive cough, gradual HA and malaise, wheezing, F, diffuse infiltrates.

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40
Q

What are some causes of fungal pneumonia?

A

Blastomycosis, Histoplasmosis, coccidioidomycosis

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41
Q

Name diagnostics for pneumonia

A

CXR (Gold standard, but may not show early pneumonia), blood and sputum cultures usually for hospital or refractory cases

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42
Q

What is a basic plan for treating pneumonia?

A

Uncomplicated (haven’t had abx in 3months and is CAP)= Macrolide/Doxy. If complicated: Levofloxacin.

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43
Q

Tony is a 24 y/o male college basketball player with sudden onset dyspnea/pleuritic pain. What do you think is happening?

A

Spontaneous pneumo

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44
Q

How do you determine if you will treat a spontaneous pneumo?

A

CXR, if pneum<3cm watch for 6 hours. If greater than 3 cm, persistent or tension pneumo then chest tube.

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45
Q

Claire is a 2 y/o who has sudden onset dyspnea. Mom can’t figure out what is going on and she has no other symptoms that suggest infection. What do you suspect and how can you manage it?

A

foreign body aspiration

CXR, bronchoscopy

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46
Q

Your preceptor is pimping you: Hey newbie, we’ve got this patient who had mild inhalation injuries after a kitchen fire less than a week ago. Her chest x-ray shows bilateral opacities and some edema. She has no cardiac issues. She’s now severely hypoxic. What is going on?

A

ARDS aka Shock lung (lots of causes so not just inhalation injury)
criteria:
1.Resp. insult/sx w/in last week.
2.Bilateral opacities/Pulm edema on CXR.
3.SX not due to cardiac causes.
4.Hypoxemia.

high flow O2

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47
Q

Name some risk factors for PE

A

DVT, immobilization, surgery, CA, Smoker, obesity, HTN.

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48
Q

Name some symptoms of PE

A

Dyspnea, pleuritic pain, cough, orthopnea, leg pain/swelling, wheezing.

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49
Q

Name some key signs of PE

A

Tachypnea, Tachycardia, rales, JVD

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50
Q

What is the basic treatment plan for PE

A

Thrombolysis, inferior vena caval filters, and embolectomy

51
Q

Stewart has a past HX of asthma. He’s in the ED now because his asthma action plan show’s he’s in the red and his LABA, SABA and Steroid inhalers aren’t helping. His PEFR is less than 50%, he’s using accessory muscles and speaking in short and labored sentences. His SPO2 is dropping below 95%…..what is happening and how will you treat it?

A

Status asthmaticus (doesn’t respond to meds)

ABC: albuterol, O2, Ipatropium bromide, systemic corticosteroids, mag sulfate.

52
Q

Name two non cardiovascular causes of pulmonary edema

A

HAPE, ARDS

53
Q

Name a cardiovascular cause of pulmonary edema. How is it treated, what do you need to look at first?

A

decompensated heart failure. Check volume status first, if not hypovolemic then loop diuretic.

54
Q

A mother of 8 children comes into your clinic and all of them have colds. She wants answers: When is influenza most prevalent, how is it spread and how long is it contagious?

A

Fall/winter
respiratory secretions
1 day before and 5-7 days after

55
Q

What are the general symptoms of the flu?

A

F/HA/Myalgia/Malaise then non-productive cough, sore throat and nasal discharge

56
Q

When can you use antivirals for the flu and how do they help?

A

w/in 48 hours w/ oseltamavir or zanamivir. Shortens sx by 1 day and reduces complications.

57
Q

What sort of pharmacotherapy can you offer a patient with MI?

A
  • Antiplatelet -ASA 162/325mg in acute setting, 81mg non acute.
  • (determine if they are candidates for fibrinolytic therapy)
  • Nitro to lower afterload for HF and dilate coronary vasc.
  • If no signs of HF(bradycardia, hypotensive, etc.) then BB
  • Morphine for anxiety and discomfort.
  • Statin
  • PCI if available, Fibrinolytics if qualify.
58
Q

Avery is a 65 year old farmer who has dyspnea. He says its worse when he lays down and he frequently wakes up short of breath and needs to go to an open window to feel like he’s getting enough air. He has also noticed that he gets fatigue when he works out in the fields now and his legs have been swollen. This is all getting in the way of work for him. What is going on?

A

congestive heart failure

59
Q

You are conducting a PE on a 55 y/o man who comes in complaining of fatigue. You check his pulse and it alternates between week and stong pulsations. When you examine his precordium you notice that instead of being over the 5th rib on the midclavicular line, his apical impulse seems more lateral. What is this a sign of? What might you hear on auscultation consistent with this finding?

A

HF, you might hear S3 if LVH esp. Systolic or dilated HF.

S4 is more characteristic of LVH w/ diastolic or hypertrophic HF.

60
Q

You push on your patient’s liver for 10 seconds and watch his left external jugular vein. You palpate for a pulse over where you are watching on his neck first to make sure you don’t feel one (if so it would be his carotid). The vein stays distended rather than distending and going back to normal. What is this test and what does it mean?

A

Hepatojugular reflux test for JVP. Right sided heart failure.

61
Q

What lab can you order that indicates heart failure?

A

BNP. If it’s greater than 400 and the patient is over 50 it’s a positive finding. Levels depend on age so it needs to be higher for folks that are older.

62
Q

General treatment plan for congestive heart failure

A

-diuretic,
low sodium diet,
ACE-i for LVEF<40%.
Can progress to use BB, then Hydralazine, then Digoxin stepwise.

63
Q

Winston comes to the clinic because he gets chest pain when he breathes that is worse when he lays down. You auscultate and hear a rub. What might you find on an ECG? How will you treat this?

A

Pericarditis
ECG: wide spread ST elevation and PR depression
NSAIDS and Pericardiocentesis

64
Q

Matt is a 50 year old who is in for a check of his blood pressure and refill of his Losartan. The nurse comes to tell you that she’s taken multiple BP reads and they are all over 180 systolic and/or 120 diastolic. You draw a labs and find signs of kidney failure. What should you do and in what time frame?

A
  • systolic pressure ≥180 and/or diastolic pressure ≥120 mmHg + EOD.
  • lower BP over 24 hours. Nitroprusside or Hydralazine if prego
65
Q

Your patient is becoming hypotensive and has dyspnea. She had a mild pericardial effusion that was drained 2 days ago. Now you see increased JVP and noted pulsus paradoxus (systolic BP decreases w/ inspiration). What do you suspect?

A

Cardiac tamponade

Echo would show effusion plus chamber collapse and bowing of septum.

66
Q

What might you suspect with patients who don’t fit the mold for HF (not your old patient with chronic HTN and hx of MI), but show signs like S3/S4, fatigue, chest pain, arrhythmia and enlarged heart. What might be some causes?

A

Cardiomyopathy

viral (chagas, strep/rheumatic) autoimmune (lupus), idiopathic/genetic, alcoholic….

67
Q

You are in the ED and Bob comes in. He is a white male, looks over 65 in age and smells of cigarette smoke. He is complaining of severe abdominal/back/flank pain and looks shocky.

A

AAA….he needs fluids titrated to 80-90 systolic, bright lights and blades.

68
Q

Should you screen for AAA?

A

USPSTF GRADE B Recommendation: Men who are ages 65 to 75 and who have ever smoked should be screened one time for AAA by abdominal ultrasonography.

69
Q

Where do you measure for AAA and what is normal?

A

Bifurcates at umbilicus. NL </= 3cm.

70
Q

How are sinus blocks, av blocks, etc. treated?

A

If asymptomatic, nothing.

If symptomatic, tx per ACLS, then pacemaker

71
Q

Patient comes in with pain, pulselessness, pallor, paresthesias, paralysis, and poikilothermy of their leg. What is this and what do you do?

A

Accute arterial occlusion

-Initiate heparin, angiography, cath directed thrombolysis or surgery.

72
Q

Name two types of acute venous occlusion. Describe how they present and how they are treated

A
  1. superficial: red,swollen extremity that is tender along length of vein: warm compresses, NSAIDS, follow up.
    2.Deep: red, swollen, painful extremity.
    tx w/ heparin bridged to warfarin. Heparin for 5 days/ when INR is 2.5 for two days.

Duplex US for dx

73
Q

A 62 year old man w/ past history of MI, ASCVD, and a-fib presents with rapid onset and severe periumbilical pain. He’s had bloody stools as well as nausea and vomiting. What do you suspect? How can you confirm this? TX?

A

acute intestinal ischemia

CT-A

Tx like you would clots elsewhere w/ heparin. They need surgical revascularization.

74
Q

What are two things that are commonly investigated when trying to figure out the cause of an ischemic stroke?

A
  • arrhythmia

- coagulopathy

75
Q

Evidence shows benefit from alteplase therapy for ischemic strokes within what time frame?

A

4.5 hours.

76
Q

What is a common site for cerebral aneurysms?

A

junctures from off the circle of willis

77
Q

Name some risk factors for cerebral aneurysms

A 
women
Ehlers-Danlos syndrome
PKD, 
family Hx, 
HTN, 
smoking, 
alcohol.
78
Q

A patient comes into your clinic this morning complaining of severe head ache and some visual acuity loss. On exam you notice their left eye is oriented down and out and is unresponsive to light. What do you suspect and how can you work this up?

A

Cerebral aneurysm w/ 3rd nerve palsy
CT-A or MR-A

If large or symptomatic surgery is indicated. If not, then monitor.

79
Q

Two patients are in the ED, one has viral/aseptic meningitis, the other has viral encephalitis. How do their symptoms differ?

A

meningitis: fever and headache with meningismus, lethargy
encephalitis: also have mental status changes and or focal deficits.

80
Q

What are some causes of encephalitis?

A
  • mumps (look for parotitis)
  • west nile (look for rash and paralysis).
  • Rabies ( hydrophobia/aerophobia/hyperactivity/phyrangeal spasms)
  • HSV
  • Varicella (dermatomal rash)
81
Q

What diagnostics will you do for encephalitis and what sort of empirical treatment will you start?

A
  • CSF PCR for HSV-1 and IgM antibody on CSF and serum for West Nile virus
  • rapid initiation of acyclovir 10 mg/kg three times daily
82
Q

Mr. Williams is a 70 year old male who comes to the ED w/ acute onset confusional state. You attempt to gather a history from him, but he can’t seem to pay attention and keeps zoning out. When he does communicate he behaves anywhere from lethargic to agitated. What do you suspect? What should you do?

A

Delirium
Do solid PE and run the gamut of labs to figure out the cause. Give reassurance and have family close. Haloperidol if harming selves or others.

83
Q

Tammy comes into clinic complaining of a gradual onset headache that started this morning. She says she knew it was going to start because she always feels warm and nauseated before she gets these headaches. It’s unilateral and seems to be aggravated by loud sounds and bright lights. What do you suspect? How will will you treat it today? If it becomes a chronic problem?

A

Migraine: often unilateral, gradual, crescendo, phono/photophobia, N/V up to 72hrs, possible aura.

Acute: NSAID + Triptan.
Chronic: BB, CC or valproic acid (anticonvulsant)

84
Q

Linda comes to clinic complaining of a headache that is bilateral and described as tightness around her head. It comes and goes and is really bothering her because she is having them frequently. What do you suspect? How will you treat it today? If it becomes a chronic problem?

A

Tension HA: most common, bilateral tightness that comes and goes.
Acute: NSAID.
Chronic: TCA

85
Q

James comes to clinic c/o HA. His right eye is watery and he seems to have a runny nose. He says his HA is just on the right side and feels like its behind his eye and temple area. What do you suspect? How will you treat it today? If it becomes chronic?

A

Cluster HA: always unilateral around eyes or temple, lacrimation, rhinorrhea, sweating, 30mn-3hrs.

Acute:Triptan and O2
Chronic: Verapamil for prevention.

86
Q

What are some red flags for headaches that warrant MRI?

A
  • neurologic abnormalities,
  • meningismus,
  • Fever/HTN,
  • signs of trauma to head,
  • papilledema,
  • bruits,
  • onset of HA w/ exertion i.e. cough/ sexual activity,
  • new onset over 40 yoa,
  • change in pattern and getting worse.
87
Q

What are some causes of syncope?

A
  • Carotid hypersensitivity
  • Arrhythmia
  • Ischemia from ACS
  • Hemorrhage
  • Orthostatic (hypovolemic, deconditioned/too much bed rest, autonomic dysfunction)
  • Drugs (vasoactive, antiarrhythmic, CC, BB).
88
Q

What are some causes of seizures?

A
  • metabolic
  • drug
  • vascular
  • hematologic
  • head trauma
  • infection
  • stroke
  • congenital brain malformation
89
Q

What is a possible lifestyle modification you may need to implement for a patient with seizures?

A

Driving restrictions

90
Q

You are at the movie theater and the man next to you has one continuous, unremitting seizure lasting longer than five minutes. What is this and what is the treatment?

A

Status epilepticus: one continuous, unremitting seizure lasting longer than five minutes, or recurrent seizures without regaining consciousness between seizures for greater than five minutes.
Benzo

91
Q

Mrs. Jacobs comes into the ED with sudden onset facial droop and left sided weakness. Her symptoms resolve before you get any work up started. What was this?

A

Stroke until proven otherwise w/ neuroimaging and full exam

92
Q

What is the definition of a TIA?

A

Patient has transient neurological dysfunction without infarction. Have to get diagnostics to prove this, otherwise it’s a stroke.

93
Q

T/F: TIA is associated with increased risk of more strokes

A

TIA is associated w/ high early risk of recurrent stroke

94
Q

What is the general management for a patient who had a TIA if you find A-fib during your work-up?

  • if you find carotid stenosis?
  • no abnormal findings?
A
  • If A-fib then anticoagulation.
  • If carotid stenosis then consider carotid endarterectomy. - In general: Control BP, take statin and ASA, stop smoking and change lifestyle.
95
Q

What are 2 late signs of neurosyphillis?

A
  • Paresis: progressive dementia, tremors, dysarthria.

- Tabes dorsalis: ataxia, pupillary irregularities (constricted and weak response), absent reflexes.

96
Q

What is an early sign of neurosyphilis?

A

meningitis

97
Q

What’s the basic workup and treatment for syphilis?

A

VDRL, RPR, LP: if positive PEN G.

98
Q

Ed is a 50 year old male who is constantly dehydrated. He has medical hx of gastric bypass and HTN. He comes in to clinic today with severe flank pain. He says it comes in waves. He has thrown up once this morning and says it hurts when he goes pee. His UA shows hematuria. What do you suspect? How will you treat this?

A

Kidney stone
DX: x-ray, US, non con CT (test of choice)
TX: pain meds and hydration till stone passes. If >4mm then tamsulosin to help w/ passage, then send to urology.

99
Q

You are assigned to work up a patient in the ED and the only complaint you have is oliguria….what is on your differential?

A
  • hypovolemia
  • renal failure
  • urinary obstruction
  • DKA
  • HHNS
100
Q

What are most kidney stones made of?

A

Calcium

101
Q

Aside from Calcium, what are some other types of kidney stones?

A

Uric acid
Struvite
cysteine

102
Q

At what point in a kidney stone’s progress through the GU system do symptoms typically begin?

A

Once the stones enter the ureter.

103
Q

A paramedic calls in a patient that has a kidney stone. What are the symptoms?

A

mild to severe flank pain that comes in waves, hematuria, N/V, dysuria, urgency

104
Q

What are some diagnostics to use for finding kidney stones?

A

x-ray, US, non con CT (test of choice)

105
Q

How are kidney stones treated?

A

pain meds and hydration till stone passes. If >4mm then tamsulosin to help w/ passage, then send to urology.

106
Q

Mike just developed severe pain in his left testicle. What might he notice about the position of his testicle? What might a provider test on PE that would be consistent w/ testicular torsion? If this is a torsion then what is the plan?

A
  • Bell clapper deformity/transverse lie
  • absent cremaster reflex
  • Doppler US. If surgery available: detorsion, explore for infarct and orchiopexy. If not then manual detorsion.
107
Q

Steve’s cheek is swollen, he feels tired and achy. Now his right testicle hurts and is red and swollen. What do you suspect?

A

Orchitis secondary to mumps, a self limited viral syndrome (swollen cheek is parotitis). Ice, elevate and take NSAIDS. May be both testicles.

108
Q

Chastity thinks she has the flu. She had a fever, chills and low abdominal pain that is worse with defecation. At the clinic, she starts feeling right upper quadrant pain too. On physical exam, a pelvic exam is performed and her cervix is tender to any movement. What is going on? How will you treat it?

A

Pelvic inflammatory disease.

  • multiple organisms including chlamydia and gonorrhea, strep, gardnerella, G-‘s.
  • SX: Lower abdominal pain, vaginal discharge, dysuria, pain w/ defacation. Fever, chills and possible perihepatitis (Fitz-Hugh–Curtis syndrome) causing RUQ pain
  • TX: Ceftriaxone, doxy and metro if instrumentation in past 2 weeks.
109
Q

Bob’s testicle hurts. He has fever, chills and it hurts to pee. He feels better when he lifts up his testicle and notices that the swelling and tenderness seems to be at the top and back part of his testicle. What do you think this is? What may have caused it and how can you treat it?

A
  • Epididymitis
  • Can be infectious, traumatic, autoimmune
  • TX: Get culture. Ice, elevation, NSAIDS. Ceftriaxone + doxy if suspect gonorrhea, or if >35 and don’t suspect gonorrhea then ofloxacin
110
Q

Martin is a 75 year old patient who comes in complaining of scrotal pain. On PE you note that he is febrile and find bullae, crepitus and tenderness of the perineum…what do you suspect?

A

Fournier’s gangrene.

111
Q

Morgan is a 54 year old plumber. Yesterday he had some intermittent flank pain and started feeling increase in urge to pee, increased frequency and some pain with urination. He woke up this morning with fever, chills, nausea and vomiting. What is this? Where might you find tenderness on PE? Under what circumstances should you admit him? How will you treat this?

A

pyelonephritis: complicated UTI, often E. coli, enterobacter, klebsiella, pseudomonas.

CVA tenderness

SX: LUTS + Fever, chills, flank pain, CVA TTP, N/V.

TX: C&S guides TX.
-outpatient: Cipro 500 BID x 10.

-If complicated: prego or any condition that increases risk of therapy failure (immunosuppression, DM, Sx for 7+days prior to care, etc.) admit + ABX.

112
Q

Dan is a middle aged man. Over the past few days he’s developed some pain on urination, decreased flow and dribbling, low back pain and came in today b/c he has fever and chills. What do you suspect?

A

acute prostatitis

young-middle aged men, often d/t E.coli or Proteus, can be from STI. Fever, chills, dysuria, pelvic/perineal pain, cloudy urine, dribbling (obstruction).

113
Q

You have a patient w/ acute prostatitis. What will the prostate present like on PE? What will UA show? How will you treat this condition?

A

Prostate feels warm, firm, edematous, EXQUISITELY tender.

UA: pyuria,bacteruria, leukocytosis. C&S. Bactrim.

114
Q

Olivia is an 8 year old who contracted a viral infection that is not identified. Aside from constitutional symptoms you note that she has petechiae and purpura on her lower extremities and has had several nose bleeds. What do you suspect? How can you treat this?

A

idiopathic thrombocytopenic purpura

viral infection, malignancy, autoimmune disease cause cross reactive anti platelet antibodies, leads to increased platelet destruction and decreased production.

Petechiae esp in dependent areas, purpura, epistaxis, possible internal hemorrhage, thrombocytopenia.

Dx of exc. TX’d by platelet transfusion, IVIG + steroids.

115
Q

Timmy is a young boy, under 10 years of age. He has had bloody diarrhea for 5 days. You decide that it’s time to treat with antibiotics even though your stool culture lab results are still pending. Instead of seeing improvement, Timmy’s symptoms of abdominal pain, diarrhea, vomiting and fever get worse and now he looks pale, is acting confused and you are finding unexplained bruises on his body, some bleeding from his nose and mouth and has stopped urinating. What is going on? Why? How can you treat this?

A

hemolytic uremic syndrome

Cardinal symptoms: hemolytic anemia (pale) + thrombocytopenia (bruises and bleeding) + AKI (hematuria and oliguria).

Usually caused by shiga toxin producing E. Coli, Pneumococcus, drug tox for transplant pt, CA, antiplatelet agents, lupus, pregnancy.

STEC HUS: abdominal pain, V/Diarrhea, fever or Pneumonia w/ pneumococcus. Always get Shiga toxin and C&S w/ your stool samples to make sure its not STEC.

Note PT, PTT d-dimer are all NL but bleeding time is increased.

TX: RBC transfusion, platelets, fluids. If pneumonia ceftriaxone IM/IV or Azithromycin PO.

116
Q

What is the difference between HUS and thrombotic thrombocytopenic purpura?

A

same as HUS but TTP has neurologic manifestations: HA, confusion, seizure

117
Q

The attending hands a patient off to you and only tells you that the patient was septic and now has disseminated intravascular coagulation…how does this present? What causes it? How do you treat it?

A
  • caused by sepsis, trauma, CA.
  • presents with hemolytic anemia, Thrombycytopenia,
  • coags show prolongued PT and PTT, bleeding increased. lots of fibrinolysis (high d-dimer).

Give platelets and plasma.

118
Q

TTP, ITP, HUS vs DIC how do they differ in terms of labs?

A

TTP, ITP, HUS :PT, PTT d-dimer are all NL but bleeding time is increased.
DIC: prolonged PT and PTT, bleeding increased. lots of fibrinolysis (high d-dimer).

119
Q

Willis is a 23 year old man who comes in complaining of severe pain in his legs, back and abdomen. His mucus membranes look pale and he’s developed a priapism. What do you suspect? What are two findings you might find on a blood smear?

A
  • sickle cell crisis: vaso occlusive crisis.
  • painful episodes of bilateral symmetric bone pain back, legs, arms and abdomen. Symptomatic anemia, susceptibility to infection, stroke, cardiopulmonary complications, renal involvement, leg ulcers, and recurrent priapism in males.
  • Blood smear shows sickled cells and howell jolly body inclusions.
  • FOR CRISIS: opioid analgesics, adequate hydration, rest

Other non urgent treatment:

-Need vaccinations: for strep pneumo, flu, Meningococcal, Hib and Hep B. ABX prophylaxis at least till 5 yoa. Folic acid supp, no iron sup.

120
Q

Susan just started her anticoagulation therapy with warfarin and heparin. She got confused and took too many warfarin pills. What symptoms might she present with? What will you use to determine treatment?

A

-INR>3

121
Q

Leroy is a chronic alcoholic. He is brought to the ED with N/V and abdominal pain and is alert. His labs are positive for ketones and gap acidosis. What is this? What caused it?

A

alcoholic ketoacidosis

malnourished chronic alcoholic bingeing w/ abdominal pain, N/V.

ETOH is metabolized to ketones and fasting/withdrawal cause catecholamine release=lipolysis = ketone release = acidosis w/ ketones. Similar to DKA, but MS usually alert.

Fluids, thiamine, dextrose, correct electrolyte abnormalities.

122
Q

Joe is a 48 year old diabetic who has had a poorly managed foot ulcer. He is brought to the ED tachypneic (he’s breathing rapidly with deep inhalations and exhalations), dehydrated and complaining of N/V and abdominal pain. What is this? What type of diabetes is more prone to present with this? What are ABG findings? How will you treat this?

A

diabetic ketoacidosis: caused by infection or poor diabetes management. SX: Abd pain, signs of volume depletion. fruity breath, kussmaul respirations. Fluid, electrolyte correction (low k), insulin

Type 1

BGL»250, pH

123
Q

Tina is a 39 year old poorly controlled diabetic. She is brought to the ED in a coma. Your preceptor tells you she is in a hyperosmolar hyperglycemic state. What does her ABG show? How will you treat this?

A

hyperosmolar hyperglycemic state
coma. Infection can cause, poor therapy.lactic acidosis. signs of volume depletion

BGL>600,pH NL, Neg ketones, non gap,

Fluid, electrolyte correction (low K), insulin.

124
Q

Trevor is a 25 year old diabetic. He comes to your clinic shaking, sweating and complaining of hunger, palpitations and paresthesias. You are pretty sure he’s drunk. On history you find out that he accidentally injected two doses of his Insulin. What is this? What is Whipple’s triad? How is it treated?

A

hypoglycemia
usually a DM pt tx’d w/ insulin. Tremor, palpitations, sweating, hunger, paresthesias, alt. MS.

Whipple’s triad: sx/signs + low BGL + resolution w/ admin of dextrose.

If not DM could be etoh, insulinoma or endocrine disorder.

E-MED (9 decks)

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